Safety

Objective – Safety

To achieve a culture of zero tolerance towards avoidable patient harms.

Patient safety is a key priority for the Trust. We are proud to have won several national awards for the innovative work we have undertaken to improve patient safety. We continue to build on this foundation as a priority to support a reduction in avoidable patient harms.

Indicators

Patient Falls

Patient falls are the most common patient safety incident reported to the National Patient Safety Agency (NPSA). In an average 800-bed acute trust there will be around 24 falls every week – over 1,260 a year. Associated healthcare costs are estimated at a minimum of £92,000 per year for the average acute trust (Healy and Scobie, 2007).

Patient falls is used as a key performance indicator to show the quality and safety of care given to patients while in hospital. Data for patient falls is presented below:

Key Findings

The last three years have seen a decrease in the number of patient falls per thousand days from an average of 6.84 in 2014/15, to 6.64 in 2015/16 and then to 6.76 in 2016/17. This represents a decrease of 1.17% over the three years.  In 2014/15 there were 1914 falls with harm compared with 1865 in 2015/16 and 1956 in 2016/17.  This represents an increase of 2.19%. However, the Trust recognises that there has been improved reporting of falls, which may account for the increase in number of incidents.

 Patient falls are one of the most common patient safety incidents reported.  The majority of slips, trips and falls result in low or no harm to patients physically. However, any slip, trip or fall can result in the patient losing their confidence.  There have been a number of initiatives introduced throughout the Trust.

To view these initiatives, click here

Pressure Ulcers

The number of patient harms as a result of a pressure ulcer is used as a key performance indicator to show the quality and safety of care given to patients while in hospital. Data for pressure ulcers is presented below:

There have been a number of initiatives to reduce patient harm as a result of a pressure ulcer introduced throughout the Trust.

To view these initiatives, click here

 

 

Medication Errors

Medication errors is used as a key performance indicator to show the quality and safety of care given to patients while in hospital. Data for medication errors is presented below:

Key Findings

It is vital that everyone working in clinical areas are made aware of any errors or incidents that have occurred so that lessons can be learned where necessary, and practice changed. There is a lot of training taking place within the Trust relating to administration of medicines, and most areas now ensure the Nurse who is administering medications wears a tabard to ensure minimal interruptions take place. The reporting of any medication errors is actively encouraged by the Trust.

In 2017/16 there were there were 7 patients who experienced a medication error that resulted in a moderate/serious harm.  This is a 53.3% reduction on the number of patients who experienced the same harm in 2015/16 and 75% reduction on 2014/15.

In the rolling twelve months to September 2016 there have been 504 medication errors with harm.  In year, in the 6 months to September 2017 there have been 460 medication errors with harm and at this rate we would expect to see no more than 920 medication errors with harm for 2017/18, a reduction on last year’s total of 5.25%.

 

Measures have been put into place as outlined below and it is anticipated that the Trust will continue to see a downward trend for medication errors.

 

Building on work already commenced, there have been a number of initiatives introduced to promote the reduction in medication errors resulting in patient harm:

  • Medication error working group established to determine root causes from lessons learned and implement improvement actions.
  • Medication omission error project – this has resulted in the development and implementation of a sticker to go in patient notes to determine cause of omission and actions taken from both nursing and medical staff. As a result there have been no serious harms as a result of medication omissions since its introduction in April 2017.
  • This project is now being replicated in the community hospitals.
  • Interrogation of medication errors and causes via the Medicines Management Committee, with recommendations for improvement actions.
  • Medication review process for patients experiencing a fall, in line with NICE guidance.
  • Fridge temperature check process implemented

 

Methicillin-resistant Staphylococcus aureus (MRSA)

Tackling health care-associated infections, such as MRSA, continues to be a key patient safety issue and is a priority for the NHS, as set out in the 2009/10 NHS Operating Framework and the 2007 Public Service Agreement ‘Ensure better care for all’.

MRSA bloodstream infections (bacteraemia) are a significant cause of morbidity and can be difficult to treat because of the multiple antibiotic resistances. Infections lengthen hospital stay and increase morbidity and in some cases, result in death. Reducing the incidence of infection will therefore have significant patient benefits. The aim is that action on MRSA will also help to reduce the incidence of other similar infection, through the implementation of improved infection prevention measures. Data for MRSA infections are detailed below:

Data Source: HCAI Data Capture System. Period: Monthly

Data Source: HCAI Data Capture System. Period: Monthly

Key Findings

With regards to MRSA bacteraemia, the Trust reported 3 cases against a trajectory of 3 for the year 2012/13; 1 case against a trajectory of 0 in 2013/14; 3 cases against a trajectory of 0 in 2014/15; 6 cases against a trajectory of 0 in 2015/16 and 5 cases against a trajectory of 0 in 2016/17.

There have been no recorded cases between April 2017 and November 2017. Therefore the Trust remains at 0 cases for this financial year.

A number of measures have been embedded within the organisation to prevent further cases of bacteraemia and these continue to be re-enforced. All cases of MRSA Bacteraemia are investigated through a post infection review (PIR) process, the findings of which are communicated across the Trust. We conduct Aseptic Non-touch technique (ANTT) competency training throughout the year for all staff and ensure that practice is audited annually. Saving Lives quarterly audits continue to monitor compliance and ensure practice is improved. All high risk patients admitted to the Trust are screened for MRSA as per the latest Department of Health guidance. Hand Hygiene compliance is monitored quarterly through covert hand hygiene audits and results are presented to the Divisions and monitored through the Whole Health Infection Prevention Committee.

CDIFF – Clostridium difficile infections

Tackling health care-associated infections, such as Clostridium difficile continues to be a key patient safety issue and is a priority for the NHS as set out in the 2009/10 NHS Operating Framework and the 2007 Public Service Agreement ‘Ensure better care for all’.

Mandatory surveillance for Clostridium difficile was introduced in England in January 2004 with all acute and specialist NHS trusts in England required to report all diarrhoeal samples (defined as those that take the shape of the container) from people 65 years of age or older who have not been diagnosed with Clostridium difficile infection during the preceding four weeks. Trusts are required to report all positive results, including those received from people in the community. Since 1 April 2007, trusts were required to expand this reporting to include all positive results in patients aged two years and over. Data for Clostridium difficile infections are presented below:

Data Source: HCAI Data Capture System. Period: Monthly

Data Source: HCAI Data Capture System. Period: Monthly

Key Findings

With regards to Clostridium difficile, the Trust reported 28 cases against a trajectory of 51 for the year 2012/13; 26 cases against a trajectory of 29 in 2013/14; 54 cases against a trajectory of 28 in 2014/2015; 66 cases against a trajectory of 40 in 2015/16 and 29 cases against a trajectory of 40 cases in 2016/17. The trajectory has once more been set at 40 for 2017/18 and there has been 1 case attributed to the Trust in April 2017, 6 in May 2017, 2 in June 2017, 4 in July 2017, 3 in August 2017, 4 in September, 3 in October 2017 and 7 in November a total of 30 cases.

Measures to reduce Clostridium difficile continue to be embedded within the Trust.  The Clostridium difficile reduction Strategy continues to be implemented and monitored quarterly to ensure there is a significant reduction in numbers. The antibiotic formulary has been reviewed and there has been a tightening of scrutiny and clear accountability regarding antibiotic prescribing practices in association with Clostridium difficile. Patients identified as positive for Clostridium difficile infection are managed on the isolation ward which reduces potential environmental contamination but also ensures optimal management of the patient. The Infection Prevention team continue to work closely with ward staff to identify patients who are at risk from acquiring Clostridium difficile and raise awareness of the need for prudent antimicrobial prescribing, isolation precautions and the cleaning of patient equipment. The Trust has also recently introduced a new decontamination system which uses UVC technology to help kill bacteria and viruses in the patient environment.

MSSA

Staphylococcus aureus is a bacterium that lives on the skin of approximately a third of the population. When it remains on the skin it is quite harmless, however once in the bloodstream it can cause a serious infection. Although the bacteria, is sensitive to antibiotics the infection can lengthen hospital stay. The aim is to reduce the number of incidences of MSSA blood stream infections and thereby protect patients.

Data Source: HCAI Data Capture System. Period: Monthly

Data Source: HCAI Data Capture System. Period: Monthly

Key Findings

The Department of Health directed that from the 1st of January 2011 all Trusts must report MSSA Blood stream infections on the Healthcare Associated Infections Database. Currently the Department of Health have not set a reducing trajectory for Trusts to be measured against. For the year 2012/13 the Trust had 28 incidences of MSSA Bacteraemia; 22 in 2013/14; 23 in 2014/15; 23 in 2015/16 and 29 in 2016/17.

There have been a total of 17 incidences attributed to the Trust up to the end of November 2017.

Ecoli

E. coli forms part of the normal bowel flora in humans, however, some strains have the ability to cause infections. These infections include food poisoning, or infections outside the intestinal tract such as urinary tract infections (UTIs) and bacteraemia.

Data Source: HCAI Data Capture System. Period: Monthly

Data Source: HCAI Data Capture System. Period: Monthly

Key Findings

The Department of Health directed that from June 1st 2011 all Trusts must report E. coli blood stream infections on the Healthcare Associated Infections Database. Currently the Department of Health have not set a reducing trajectory for Trusts to be measured against. The trust had 46 cases for the year 2014/2015; 40 cases in 2015/2016 and 51 cases in 2016/17. There have been 37 incidences attributed to the Trust up to the end of November 2017.